Annals for Hospitalists - November 2022
Authors: David H. Wesorick
Journal: Annals of Internal Medicine (2022)

Web ExclusivesNovember 2022Annals for Hospitalists - November 2022FREEDavid H. Wesorick, MDDavid H. Wesorick, MDFrom Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202211150 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesManaging Alcohol Withdrawal Syndrome in the Hospital Setting—A Call for Research—Tessa L. Steel, MD, MPHThere is a dearth of evidence supporting the management of alcohol withdrawal syndrome in hospitalized patients. This month's commentary discusses the state of the evidence and the need for research to inform and improve the current practice.Highlights of Recent Articles From Annals of Internal MedicineComparative Effectiveness and Safety Between Apixaban, Dabigatran, Edoxaban, and Rivaroxaban Among Patients With Atrial Fibrillation: A Multinational Population-Based Cohort StudyAnn Intern Med. 2022;175:1515-1524. Published 1 November 2022. doi:10.7326/M22-0511This cohort study used 5 standardized electronic health databases in Europe to analyze 527 226 propensity score–matched patients who were newly diagnosed with atrial fibrillation (AF) and newly prescribed a direct oral anticoagulant ([DOAC] apixaban, n = 281 320; rivaroxaban, n = 172 176; dabigatran, n = 61 008; and edoxaban, n = 12 722). Apixaban was associated with a lower risk for gastrointestinal bleeding than the other DOACs, whereas there were no substantial differences between the agents in rates of ischemic stroke or systemic embolism, intracranial hemorrhage, or all-cause mortality.Key points for hospitalists include:Although the DOACs are now recommended as first-line medications for stroke prevention in AF, there are few comparative data to allow clinicians to choose between them.This large observational study suggests that apixaban is associated with less gastrointestinal bleeding than the other 3 DOACs, while providing similar protection against stroke.These findings were consistent, even in patients older than 80 years and those with chronic kidney disease.Apixaban Versus Rivaroxaban in Patients With Atrial Fibrillation and Valvular Heart Disease: A Population-Based StudyAnn Intern Med. 2022;175:1506-1514. Published 18 October 2022. doi:10.7326/M22-0318This cohort study used a commercial health insurance database to compare 19 894 propensity score–matched, new users of either rivaroxaban or apixaban for AF and valvular heart disease ([VHD] defined as stenosis or regurgitation of any severity in any native heart valve). Apixaban was associated with significantly lower rates of ischemic stroke or systemic embolism (hazard ratio, 0.57 [95% CI, 0.40 to 0.80]) and gastrointestinal or intracranial bleeding (hazard ratio, 0.51 [CI, 0.41 to 0.62]).Key points for hospitalists include:Although both rivaroxaban and apixaban are prescribed frequently for patients with AF and VHD, there are no head-to-head trials of these drugs in this population.This observational study suggests that apixaban may be superior to rivaroxaban in patients with both AF and VHD, as it is associated with both lower rates of stroke and bleeding.Database limitations (for example, lack of data on the cause and severity of the VHD, inability to confirm medication adherence) should be recognized when interpreting these results.In the Clinic: Preoperative Evaluation for Noncardiac SurgeryAnn Intern Med. 2022;175:ITC161-ITC176. Published 8 November 2022. doi:10.7326/AITC202211150This review article provides an overview of the perioperative evaluation of patients undergoing noncardiac surgery.Key points for hospitalists include:Perioperative cardiac risk stratification should include the use of a formal risk calculator tool (for example, the Revised Cardiac Risk Index, the American College of Surgeons National Surgical Quality Improvement Program risk calculator, or the myocardial infarction or cardiac arrest tool) and consider the patient's functional capacity, the procedural risk, and the urgency of surgery. Existing guidelines differ as to when or if they recommend the use of biomarkers or noninvasive cardiac testing.The authors recommend the use of the Duke Activity Status Index to estimate functional capacity in the preoperative setting, as subjective estimates do not correlate with patient performance on formal testing or postoperative cardiac outcomes.Coronary revascularization is rarely required to prepare a patient for noncardiac surgery, and such procedures should be reserved for those patients who would require revascularization, even without the noncardiac surgery.The largest study of perioperative β-blockers found a reduction in myocardial infarction but an increase in stroke and overall mortality. This study has resulted in recommendations against the routine use of perioperative β-blockers in most patients but has been criticized for its dosing protocol (that is, the use of high-dose, extended-release metoprolol, which may have led to high rates of hypotension and bradycardia).Patients should continue dual-antiplatelet therapy for at least 4 weeks after a bare-metal coronary stent, for at least 6 months after a drug-eluting coronary stent, and for 12 months if either type of stent is placed in the setting of an acute coronary syndrome. For patients with drug-eluting stents requiring more urgent surgery, interruption of dual-antiplatelet therapy may be considered after 3 months if the risk of surgical delay outweighs the risk for an ischemic event. Aspirin should be continued perioperatively for patients with any coronary stent unless bleeding risk precludes it.The Latest Highlights From Journal ClubAre the heart failure with preserved ejection fraction (HFpEF) benefits of empagliflozin dependent on diabetes status?In HFpEF, the benefit of empagliflozin on a composite of CV death or HF hospitalization at 26 mo did not vary by diabetes statusAnn Intern Med. 2022;175:JC111. doi:10.7326/J22-0075This subgroup analysis of the EMPEROR-Preserved [Empagliflozin Outcome Trial in Patients with Chronic Heart Failure With Preserved Ejection Fraction] shows that empagliflozin reduces the relative risk for heart failure hospitalization to a similar degree in patients with and without diabetes.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: David H. Wesorick, MDAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Disclosures:Author has reported no disclosures of interest. Forms can be viewed at https://rmed.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-2807. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Managing Alcohol Withdrawal Syndrome in the Hospital Setting—A Call for Research Tessa L. Steel Metrics November 2022Volume 175, Issue 11Page: HO11 ePublished: 15 November 2022 Issue Published: November 2022 Copyright & PermissionsCopyright © 2022 by American College of Physicians. All Rights Reserved.Loading ...